Medical Documentation Requirements: Veterans Choice ... · Medical Documentation Requirements:...
Transcript of Medical Documentation Requirements: Veterans Choice ... · Medical Documentation Requirements:...
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Medical Documentation Requirements: Veterans Choice Program (VCP) and
Patient-Centered Community Care (PC3)
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Background
Department of Veterans Affairs (VA) needed to
expand health care access for Veterans in
communities across the nation
VA awarded TriWest the Patient-Centered Community
Care (PC3) contract in 2013
In 2014, Congress introduced and President Obama
signed into law the Veterans Access, Choice and
Accountability Act
Section 101 established the Veterans Choice Program
(VCP) and went live on Nov. 5, 2014
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Medical Documentation Overview
Medical documentation must be submitted to TriWest
for all services to ensure coordination of care for
Veterans
Submit medical documents before submitting claims
Specific specialty providers have additional
documentation requirements
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Medical Documentation Submission Process
Step 1 – Submit medical documentation to TriWest
Upload to Provider Portal at www.triwest.com/provider
Documents up to 5 MB can be uploaded in PDF or TIF format
Fax (if portal not available) to 1-866-259-0311
Step 2 – Submit claims to Wisconsin Physicians
Service (WPS), TriWest’s claims processor
Electronic: call WPS at 1-800-782-2680 (Option 1) to
set up EDI
Mail: mail paper claims to:
WPS-VAPC3
PO Box 7926
Madison, WI 53707-7926
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Medical Documentation Requirements
Outpatient care:
VCP: submit to TriWest within 75 calendar days
PC3: submit to TriWest within 14 calendar days
VA requires medical documentation include the initial
appointment and end-of-episode-of-care records
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Inpatient care:
Submit to TriWest within 30 business days after
discharge
Urgent specialty care:
VCP: submit to TriWest within 2 business days
PC3: submit to TriWest within 48 hours
Oral reports should be provided to VA POC within 48
hours when indicated on the authorization form
The authorization may request medical documentation
be returned sooner based on clinical need
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Medical Documentation Requirements (cont.)
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VA has medical documentation requirements for
specific specialty providers
Gastroenterology
Radiation Oncology
For easy access to this information, visit
www.triwest.com/provider and view the appropriate
Quick Reference Guide
Medical Documentation – Specialty
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Surgical procedures – complete the VA Purchased
Surgical Care Outcome form
Download the form at www.triwest.com/provider and click on
“Find a Form”
Quick reference guides available at www.triwest.com/provider
Medical Documentation – Specialty (cont.)
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Inpatient rehabilitation – complete the CMS Inpatient
Rehabilitation Facility Patient Assessment Instrument
(IRF-PAI)
The IRF-PAI example can be found at
https://www.cms.gov/Medicare/CMS-Forms/CMS-
Forms/Downloads/CMS10036.pdf
Quick reference guides available at www.triwest.com/provider
Medical Documentation – Specialty (cont.)
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Mental Health documentation should include:
Psychotherapy notes kept separate from the Veteran’s
medical record, per HIPAA regulations
Psychotherapy notes are defined as “notes recorded in
any medium by a mental health professional documenting
or analyzing the contents of conversation during a private
counseling session.”
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Mental Health documentation should also include the
items listed below and do not require Veteran
authorization for disclosure:
Medication prescription and monitoring (as appropriate)
Counseling session start and stop times
Modalities and frequencies of treatment
Results of clinical tests
Any summary of diagnosis, functional status, treatment
plans, symptoms, prognosis or progress
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Critical Findings
VA defines Critical Findings as a test result value or
interpretation that, if left untreated, could be life-
threatening or place the Veteran at serious risk
Critical values/results are results from laboratory,
cardiology, radiology and other diagnostic areas that
upon analysis are determined to be “critical,”
regardless of the ordering priority
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Critical Findings (cont.)
VA requires that for any Critical Finding test result, the
provider shall:
Notify the VA point of contact (POC) by phone (as listed
on the authorization/referral) within 24 hours of the
test/evaluation/treatment
Note in the medical documentation that the VA POC
was notified of this Critical Finding and include the date
of the notification
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Critical Findings (cont.)
A newly identified suicide risk in a Veteran not referred
for inpatient mental health should be considered a
Critical Finding
Provider shall contact VA by phone within 24 hours
A new diagnosis of cancer should be considered a
Critical Finding - notify your VA POC within 48 hours
of diagnosis
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Urgent Follow-Up and Additional Care
If a provider determines the Veteran requires:
Urgent follow-up after completion of episode of care, or
Urgent additional care during the episode of care …
Notify the authorizing VA facility POC within 24 hours
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Quick Reference Guide
Review the Medical Documentation Quick Reference
Guide for more details on what information to include
when submitting medical documents
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TriWest Provider Portal
TriWest.com/provider: your one-stop shop for
information on filing claims and navigating VCP and
PC3
Provider handbook
Quick reference guides
eSeminars (training you can take
at your own pace)
Webinars (instructor-led online
training)
Additional resources and links to
important information
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TriWest Provider Portal (cont.)
Register for a secure account to:
Upload medical documentation
Check authorization status (including SARs)
Print authorization information
Check claims status
Visit www.triwest.com/provider and click “Register for
Secure Access”
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Thank You!